Ohio Department of Job and Family Services



Ohio Department of Job and Family Services

CHILD ENROLLMENT AND HEALTH INFORMATION

FOR CHILD CARE CENTERS AND TYPE A HOMES

This form shall be completed prior to the child's first day of attendance and updated annually and as needed.

|Child’s Name |Date of Birth |First Day at Center |

|      |      |      |

|Home Address |City |

|      |      |

|State |Zip Code |Home Telephone Number |

|      |      |      |

|Parent/Guardian Name |Relationship to Child |

|      |      |

|Home Address |Home Telephone Number |

|      |      |

|City |State |Zip |

|      |      |      |

|Email Address (if applicable) |Cell Phone |

|      |      |

|Parent's Work/School Telephone Number |Parent's Work/School Name |

|      |      |

|Parent's Work/School Address |City |

|      |      |

|Please indicate if this name should be released if a parent/guardian, of a child attending the center/home, requests contact information for other |

|parents/guardians. Yes No |

|If you answered yes, please indicate which number(s) above to include on the list Work # Cell # Home # Email |

|Where can you be reached while your child is in this program? |

|      |

|Parent/Guardian Name |Relationship to Child |

|      |      |

|Home Address |Home Telephone Number |

|      |      |

|City |State |Zip |

|      |      |      |

|Email Address (if applicable) |Cell Phone |

|      |      |

|Parent's Work/School Telephone Number |Parent's Work/School Name |

|      |      |

|Parent's Work/School Address |City |

|      |      |

|Please indicate if this name should be released if a parent/guardian, of a child attending the center/home, requests contact information for other |

|parents/guardians. Yes No |

|If you answered yes, please indicate which number(s) above to include on the list Work # Cell # Home # Email |

|Where can you be reached while your child is in this program? |

|      |

|Emergency Contacts: Parents cannot be listed as emergency contacts. List the name of at least one person who can be contacted in the event of an emergency or |

|illness if you cannot be reached. Any person listed should be able to assist in contacting you. At least one person listed must be within one hour of the |

|center/home, able to take responsibility for the child in case the parent/guardian cannot be contacted and should be at least 18 years of age. |

|Name |Name |

|      |      |

|City |State |City |State |

|      |      |      |      |

|Telephone Number |Relationship to Child |Telephone Number |Relationship to Child |

|      |      |      |      |

|Other numbers where emergency contact can be reached (if applicable) |Other numbers where emergency contact can be reached (if applicable) |

|      |      |

|Name of Physician or Clinic/Hospital |

|      |

|Street Address |

|      |

|City |State |Telephone Number |

|      |      |      |

|Child’s Name |

|      |

|Allergies, Special Health or Medical Conditions, and Food Supplements |

|Fill in this section accurately and completely. Please note that if your child has a current health or medical condition requiring child care staff to perform |

|child specific care, such as: to monitor the condition, provide treatment, care, or to give medication, the JFS 01236 "Medical/Physical Care Plan" or equivalent |

|form and/or the JFS 01217 "Request for Administration of Medication" must be completed and be kept on file at the center or type A home. |

|Does your child have any food, medication or environmental allergies? (check all that apply) |

|No |

|Yes - check all that apply Food Medication Environmental Please list and explain: |

|      |

| |

| |

|Does your child’s allergy/allergies require child care staff to monitor child for symptoms, take action if a reaction occurs, or give emergency medication to your |

|child? (check one) |

|No |

|Yes - a JFS 01236 "Medical/Physical Care Plan" or equivalent form and if administering medication, a JFS 01217 |

|"Request for Administration of Medication" must be completed. |

|Does your child have a special health or medical condition? (check one) |

|No |

|Yes - please explain |

|      |

| |

| |

|Does the special health or medical condition require child care staff to perform a procedure, or perform child specific care such as: to monitor your child for |

|symptoms or administer medication during child care hours? (check one) |

|No |

|Yes - a JFS 01236 "Medical/Physical Care Plan" or equivalent form and if administering medication, a JFS 01217 |

|"Request for Administration of Medication" must be completed. |

|Is your child currently using any medication, food supplement or medical food (such as electrolyte solution)? (check one) |

|No |

|Yes - please explain |

|      |

| |

| |

|If yes, does this medication, food supplement, or medical food need to be administered at the child care center/type A home? |

|No |

|Yes - a JFS 01217 "Request for Administration of Medication" must be completed and kept on file for each medication, food supplement or medical food. |

|N/A - program does not administer any medications. |

|Does your child have any dietary restrictions, including those for medical, religious or cultural reasons? (check one) |

|No |

|Yes - please explain |

|      |

| |

| |

|Does this dietary restriction require a modified diet that eliminates all types of fluid milk or an entire food group? |

|No |

|Yes - written instructions from the child's health care provider must be on the JFS 01217 "Request for Administration of |

|Medication." |

|N/A - child does not attend a full time program. |

|Child's Name |

|      |

|List any history of hospitalization, outpatient surgery, or previous health concerns that would be needed to assist the staff or medical personnel in an emergency |

|situation. |

|      |

|List any additional information about your child that would be useful for staff to know, such as fears, eating or sleeping habits, or special routines. This |

|information should not be medical or health related, as that information should be included on the previous page. |

|      |

| |

|Diapering Statement |

|Is your child toilet trained? Yes (If yes, skip to Emergency Transportation Authorization section) No (If no, fill out the following) |

| |

|The program's policy is to check diapers every 2 hours. Please indicate if you want your child's diaper checked according to the center/type A home's policy or |

|another: |

| |

|I agree with the program's schedule I do not agree, please check my child's diaper every       hours. |

Emergency Transportation Authorization

|Give Permission to Transport |OR |Do Not Give Permission to Transport |

| | | |

| |Do not | |

| |sign | |

| |both | |

|Center or Type A Home Name | |Center or Type A Home Name |

|      | |      |

|has permission to secure emergency transportation for my child in the event | |does not have permission to secure emergency transportation for my child in |

|of an illness or injury which requires emergency treatment. The emergency | |the event of an illness or injury which requires emergency treatment. I wish |

|transportation service will determine the facility to which my child will be | |for the following action to be taken: |

|transported. | | |

| | | |

|Parent's Signature |Date | |Parent's Signature |Date |

|Acknowledgement of Policies and Procedures |

|I have reviewed and received a copy of the center's or type A home's policies and procedures/handbook. Yes No |

|(check one) |

|This form, after being completed and signed by the parent/guardian, must be reviewed for completeness and signed by the administrator/designee prior to the child |

|receiving care. After the child is attending the program the administrator shall have the parent/guardian review and initial the form when any changes/updates are |

|made and at least annually. The parent/ guardian and the administrator or designee shall initial and date the form in the section below to indicate when the form was|

|last reviewed. |

|Parent/Guardian Signature(s) |Date |

|Administrator/Designee Signature |Date |

| |

|The form is to be initialed and dated, at least annually, after it has been reviewed by the parent/guardian. This is to indicate all information has stayed the same |

|or changes have been noted. If significant changes are needed, please complete a new form. |

|Parent/Guardian Initials |Date of Review |Administrator/Designee Initials |Date of Review |

|Parent/Guardian Initials |Date of Review |Administrator/Designee Initials |Date of Review |

|Parent/Guardian Initials |Date of Review |Administrator/Designee Initials |Date of Review |

Note: This is a prescribed form which must be used by centers and type A homes to meet the requirements of rules 5101:2-12-37 and 5101:2-13-37. This form must be on file at the center or type A home on or before the child’s first day of attendance and thereafter while the child is enrolled.

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